Recently I met with a wife who felt she could not longer safely care for her husband because his dementia condition made him increasingly aggressive. Under our care in a memory unit, the gentleman exhibited similar agitation and combativeness and was assigned two of our best certified nursing assistants (CNAs), both male and both over six feet tall. I wondered how this man’s wife, petite and just shy of five feet, had managed to be a caregiver for as long as she had. After a couple days with us, someone suggested an evaluation with the psychiatrist in the hopes of reducing the resident’s outbursts and anxiety. His wife was skeptical, explaining that he had received similar medication therapy once before with very negative results. Clearly, the incident had impacted the wife greatly.
For anyone who has worked directly with people living with a dementia diagnosis, you are probably familiar with the oftentimes unpredictable behavioral changes associated with the illness. Behavioral changes, such as increased agitation and aggression that manifest in verbal or physical abuse, may present for no apparent reason or without provocation but are a part of the neurological disease process. Often, the behaviors serve as a means of communicating discomfort or unmet needs. Regardless of their origin, these behaviors are upsetting for both the individual living with the disease, as well as caregivers and family members who may regularly encounter these difficult situations.
Non-pharmacologic interventions should always be promoted as the first line of action in reducing dementia-related behaviors. Such interventions are not only emphasized by social service providers, but also by medical organizations such as the American Association for Geriatric Psychiatry, the American Psychiatric Association and the American Society for Neuropsychopharmacology. Non-pharmacologic interventions include various types of sensory therapy, such as those Christy Schoenwald wrote about in her recent blog article on engaging the senses in dementia care. Another example of a non-pharmacological intervention is dance therapy for persons with living with a form of dementia which can be used an alternative method of communication.
There are instances, however, when people living with dementia may concurrently benefit from alternative approaches, such as pharmacologic interventions, in which antipsychotic medications are prescribed to alleviate behavioral symptoms.
What are Antipsychotic Medications?
Traditionally, antipsychotics are used to treat psychosis or mood disorders such as schizophrenia or bipolar disorder. However, some studies have found these drugs to be helpful in managing potentially harmful behaviors in older adults with dementia. The prescribing of antipsychotics for dementia-related behaviors is a practice known as “off-label” use. Over the past decade, various studies have been produced mixed results in determining the efficacy of such treatments. In addition, different types of antipsychotics have produced different risks, as illustrated in a recent article published in the British Journal of Medicine (BMJ).
Are They Harmful?
There are documented adverse effects for older adults taking antipsychotics, which can be attributed to increased frequency of use and slower metabolic rates in this population. Some of the most common side effects include increased risk of falls, delirium, and oversedation. As written in the article “Illegal Use of Chemical Restraints in Illinois Nursing Homes,” many nursing home misuse antipsychotic to control and “restrain” resident’s with behavioral disturbances. Most importantly, the off-label use of antipsychotics in people living with a form of dementia has been linked to increase mortality at a rate of 1.7 times that of normal mortality rates.
Black Box Warning
As a result of the increased mortality rates, the Food and Drug Administration (FDA) administered a black box warning – the strongest warning issued by the FDA – on all antipsychotics in 2008, highlighting this increased risk of mortality in older adult patients. Utilization rates of antipsychotics in people living with a form of dementia have been declining over the past decade, most likely in response to federal oversight. According to the guidelines dictated by the Centers for Medicare and Medicaid (CMS), nursing home residents on antipsychotics must receive gradual reductions in doses, as well as behavioral interventions to compliment pharmacologic interventions.
Weighing In: Risks and Benefits
Defenders of antipsychotics claim that pharmacologic interventions are sometimes necessary and beneficial to a person suffering from constant agitation or who poses an immediate threat to himself or others. Additionally, not all antipsychotics are created equal,and some carry more risks than others. With an increase in knowledge and education, practitioners are learning how to best administer these drugs in a unique population. Continuous monitoring for side effects, low dosing, and short timeframe of use are all contributing to more prominent best practice guidelines.
What do YOU Think?
I’d love to hear your thoughts on this subject, and what experiences or encounters you have had that stand out for you. Is there room for compromise?
**This article was edited by Jaimie Robinson. The picture was taken by michaelll on flikr.com